Cesarean Surgical Techniques - GLOWM

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CesareanBirth:SurgicalTechniques|GLOWM
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Thischaptershouldbecitedasfollows:
Naji,O,Abdallah,Y,etal,Glob.libr.women'smed.,
(ISSN:17562228)2010DOI10.3843/GLOWM.10133
Thischapterwaslastupdated:
November2010
CesareanBirth:SurgicalTechniques
OsamaNaji,MBChB,DFSRH
InstituteofReproductiveandDevelopmentalBiology,ImperialCollege,London,UK
YazanAbdallah,MD
InstituteofReproductiveandDevelopmentalBiology,ImperialCollege,London,UK
SaraPatersonBrown,FRCS,FRCOG
QueenCharlotte'sandChelseaHospital,ImperialHealthcareTrust,London,UK
INTRODUCTION
HISTORY
EPIDEMIOLOGY
CLASSIFICATIONANDINDICATIONS
TECHNIQUE
SPECIALSITUATIONS
COMPLICATIONS
CONCLUSION
REFERENCES
INTRODUCTION
Acesareansectionisthedeliveryofafetusthroughanabdominalanduterineincisiontechnically,itisa
laparotomyfollowedbyahysterotomy.1Thisdefinitionconsidersonlythelocationofthefetusandnot
whetherthefetusisdeliveredaliveordead.Overrecentdecades,cesareandeliveryhasbecomemore
commonlyused,andthisincreasehasgeneratedanumberofcontroversialissues,includingtheoptimum
rate,whatconstitutesasuitableindicationandwhatisthebesttechnique.
Legendsandmythsabouttheabdominaldeliveryofaninfantappearinmanycultures.Oneoftheearliest
GreekmythsincludesthebirthofAesculapius,whoaccordingtolegend,wascutfromhismother's
abdomenbyApollo,Bacchus,andJupiter.2LegendholdsthatJuliusCaesarwasalsodelivered
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abdominally,buthismother'ssurvivalwellintoadultlifemakesthestoryhighlyunlikely.Itisthebirthof
Caesarthatsomeauthorshaveattributedtotheoriginofthetermcesareandelivery.1, 3Another
possiblesourceforthetermistheLatinverbcaedare,meaningtocut,orthetermforthechildrenwho
werebornbypostmortemcesareansections,whowerecalledcaesones.TheRomanlawLexRegis,which
datesfrom600BC,requiredthatinfantsbedeliveredabdominallyaftermaternaldeathtofacilitate
separateburialthishasalsobeenproposedastheoriginoftheterm.Thespecificlawinquestionwas
calledtheLexCesare.4, 5
HISTORY
HistoricrecordsthateludetotheperformanceofcesareansectiondatebackasfarasthefifthcenturyBC
andseemtoimplythattheoutcomesforbothmotherandchildwerefavorable.1Theearliest
authenticatedreportofachildwhosurvivedcesareanbirthisadocumentdescribingthebirthofGorgias
inSicilyinapproximately508BC.4Therearenootheraccuratedescriptionsoftheperformanceofa
cesareansectionortheimmediateoutcomeofthemotherortheneonateuntil1610.1
GabertandBeyassessedtheevolutionofcesareansectionbydividingitsdevelopmentintothreeeras:
before1500,between1500and1877,andfrom1878untilthepresent.1Before1500,referencesto
cesareansectionareoftencloudedinmysteryandmisinformation,althoughsomereligioustextsleadus
tobelievethatcesareansectionswereperformedwiththesurvivalofboththemotherandtheinfant.
After1500,theavailableliteraturedescribingdeliverybycesareansectionandthesuccessofthe
operationismoreplentiful.In1500,Nuferisreportedtohaveperformedthefirstsuccessfulmodern
cesareansection,withboththemotherandinfantsurviving.Theauthenticityofthisreportisdoubtful,
becauseitwasnotdocumenteduntil82yearsaftertheoperationwasperformed.InhisbookTreatiseon
CaesareanSectionpublishedin1581,Roussettadvisedthatthecesareanoperationbeperformedona
livingwomanassuch,hewasthefirstphysiciantodoso.4In1610,Trautmannperformedawell
documentedcesareansectioninWittenberg.Unfortunately,thepatientdiedfrominfectious
complicationsonpostoperativeday25.In1692,apatientwhohaddied14yearsafterdeliveringachildby
cesareansectionunderwentautopsy.Theaccuracyoftheclaimedcesareansectionwasvalidatedby
findingawellhealedscaronheruterus.
Duringthistimeperiod,thecesareanoperationremainedcrudeatbest.Theabdominalincisionwasmade
lateraltotherectusmuscles,andtheuteruswasincisedatwhicheverportionwasaccessiblethroughthe
laparotomyincision.Theuterinemusculaturewasnotreapproximated,andthepatienthadtobe
physicallyrestrainedduringtheprocedurebecauseanesthesiawasnotavailable.1
Closureoftheabdominalincisionslowlyevolvedfromchoosingtoleavethewoundopenandapplyonly
bandagestoallowhealingbysecondaryintentionthroughclosingonlytheskintofullclosureofthe
abdominalwall.Earlysurgeonsoftensuturedtheuterineincisiontotheanteriorabdominalwallto
encourageadhesionformationtoreinforcetheuterusandallowittotoleratefuturegestations.1Thefirst
reportofuterineclosurewasnotuntil1769.Uterineclosurewasassociatedwithdecreasedperioperative
bloodloss.Drainageofthesurgicalsitewasalsointroduced.
Bythemoderneraofcesareansection(1878topresent),severalmodificationswerebeingmadeinthe
cesareanoperation.ThePorrooperationwasinstitutedandbecamepopularintheUSandEnglandasit
becameevidentthatthisprocedurewasassociatedwithdecreasedmaternalmortality.Theoperation
consistedofalaparotomyandhysterotomyfollowedbysupracervicalhysterectomyandbilateral
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salpingooophorectomy.Therationalebehindthisradicalcesareansectionwasthatwithremovalofthe
uterusandadnexa,theratesofuterineinfection,sepsis,andhemorrhagewoulddecrease.1, 4Sterilityand
prematuremenopausewereunfortunatesideeffectsofthePorroprocedure.
ThefirststeptowardthecesareanoperationasitiscurrentlyperformedwasdescribedbySanger.4, He
proposedaprocedurethatwasmuchlessradicalanddesignedtoconservefertility.Hisoperationdidnot
involvehysterectomyandsalpingooophorectomy,butinsteadconsistedofremovingtheperitoneum
fromaportionoftheanterioruterinewallandperforminga2cmwidewedgeresectionoftheanterior
uterinewall.Thewedgewascutsothatathickedgeofmyometriumwasadjacenttotheperitoneumanda
thinedgewasadjacenttotheendometrialcavity.Thesemodificationsallowedtheserosaledgestobe
incorporatedintotheclosurewithinterruptedsilksutures.1, 4Thetechniquewasfurtherimprovedby
Garrigues,whodidnotresectthemyometriumbutinsteadsimplyclosedtheuterineincision.Other
modificationsincludednotdissectingtheuterineserosafromtheuterusandtheintroductionofsilver
wiretoapproximatethemyometriuminadditiontotheinterruptedsilksuturesontheserosalsurface.1
Asoperativetechniquesimprovedcesareansectionbecamesaferandcouldbeusedatanearlierstagein
difficultlabors.Furthermodificationsemergedincludingemptyingthebladderandrectum
preoperatively,withcathetersandenemas,respectively,todecreasethevolumeoftheseorgansinthe
operativefield,therebyreducingtheriskofinjuryduringthesurgicalprocedure.Preoperative
antimicrobialpreparationwasintroducedbyListerin1876andincludedshavingtheoperativeareaand
applyingantisepticsolutionstotheoperativefield.Vaginaldouchingwasalsointroducedandroutinely
performedbeforeperformingcesareandeliveries.1
Thetechniqueoflaparotomyandsiteofhysterotomyincisionwerevigorouslydebatedandmodified.
Abdominalincisionsweremadetotherightorleftoftherectusmusclesorinthemidlinealongthelinea
nigra.Theuterineincisionwasmadeverticallyinthemidline,obliquely,transverselythroughthe
contractilemyometrium,laterally7.210cmfromthefundus,orontheposterioraspectoftheuterus.1
Johnsonfirstdescribedalowersegmentuterineincisionin1786.1In1908,Selheimsuggestedthata
uterineincisionmadeintheloweruterinesegmentratherthanthecontractilesegmentofthe
myometriumwoulddecreasebloodlossatsurgeryanddecreasebloodlossintheeventofuterine
dehiscence.1, 4
Thedevelopmentofthemoderncesareanoperationhasnotbeenarecentaccomplishmentbutinstead
representsaseriesofinnovationsovermanycenturies.Manyaspectsoftheoperationasitiscommonly
performedtodayarenotbasedonrandomizedtrialortechniquesthathavebeenproventobesuperiorby
rigorousstudy,butinsteadaretheculminationofmanyyearsoftrialanderror.
EPIDEMIOLOGY
Cesareansectionrateisdefinedasthenumberofcesareandeliveriesoverthetotalnumberoflivebirths,
andisusuallyexpressedasapercentage.Increasingcesareansectionratesareacauseofconcerninboth
developedanddevelopingcountries.6In1985WHOstated:thereisnojustificationforanyregiontohave
cesareansectionrateshigherthan1015%.6However,overtwodecadeslater,theoptimalrateof
deliveriesbycesareansectionremainscontroversial,andthedebateregardingdesirablelevelsof
cesareansectioncontinues.Betranetal.(2007)setouttoestimatetheproportionofbirthsbycesarean
sectionatnational,regionalandgloballevels.Datawereavailablefor126countries,representingnearly
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89%ofgloballivebirthsin2002.Theglobalrateofcesareansectionwasestimatedinthatstudytobe
15%(Table1).Rateswerehigherindevelopedcountries,andinLatinAmericaandtheCaribbean,but
lowerinotherdevelopingcountries.6
Table1Cesareansectionratesbyregionandsubregion,andcoverageoftheestimates.Adaptedfrom
Betranetal.,20076
Region/subregion*
Birthsby Range,
CS(%)
minimumto
maximum(%)
Coverageofestimates
(%)
Africa
3.5
0.415.4
83
EasternAfrica
2.3
0.67.4
93
CentralAfrica
1.8
0.46.0
26
NorthernAfrica
7.6
3.511.4
84
SouthernAfrica
14.5
6.915.4
93
WesternAfrica
1.9
0.66.0
95
Asia
15.9
1.040.5
89
EasternAsia
40.5
27.440.5
90
SouthcentralAsia
5.8
1.010.8
93
SoutheasternAsia
6.8
1.017.4
83
WesternAsia
11.7
1.523.3
75
Europe
19.0
6.236.0
99
EasternEurope
15.2
6.224.7
100
NorthernEurope
20.1
14.923.3
100
SouthernEurope
24.0
8.036.0
97
WesternEurope
20.2
13.524.3
100
LatinAmericaandtheCaribbean
29.2
1.739.1
92
Caribbean
18.1
1.731.3
78
CentralAmerica
31.0
7.939.1
98
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SouthAmerica
29.3
12.936.7
90
NorthernAmerica
24.3
22.524.4
100
Australia/NewZealand
21.6
20.421.9
100
Worldtotal
15.0
0.440.5
89
Moredevelopedcountries
21.1
6.236.0
90
Lessdevelopedcountries
14.3
0.440.5
89
Leastdevelopedcountries
2.0
0.46.0
74
*CountriescategorizedaccordingtotheUNclassification.Countrieswithapopulationoflessthan
140,000in2000arenotincluded.
Referstopopulationoflivebirthsforwhichnationallyrepresentativedatawereavailable.
Theproportionofbirthsbycesareansectionhasbeenproposedasanalternativeindicatorformeasuring
access,availabilityorappropriatenessofmedicalcare,aswellasformonitoringchangesinmaternal
mortality.Inadditionrisingcesareansectionrateswillalsoreflectchangesinthedemographicriskprofile
ofpregnantwomen(age,bodymassindex(BMI)andothermedicaldisorders).
OrganisationforEconomicCooperationandDevelopment(OECD)releasedacomprehensivesourceof
comparablestatisticsonhealthandhealthsystemsacrossOECDcountrieson29June2010.7 According
toitswebsite,itisanessentialtoolforhealthresearchersandpolicyadvisorsingovernments,theprivate
sectorandtheacademiccommunity,tocarryoutcomparativeanalysesanddrawlessonsfrom
internationalcomparisonsofdiversehealthcaresystems.
ThefollowingfigurefromtheofficialOECDwebsiteshowsthecesareanratesofOECDcountriesfrom
2006to2008(Fig.1).
Fig.1CesareandeliveryrateamongOECDcountries7
Repeatcesareandeliveriesaccountforalargepercentage(37%)ofthecesareansectionsintheUS.8
Whilepatientandhealthcareprovidereducationmayreducethenumberofrepeatcesareansections
thereareotherfactorsinfluencingcesareansectionrates:forexampletherateofcesareandeliverywas
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alsoincreasedinwomenolderthan35years,inhospitalswithmorethan500beds,inforprofithospitals,
andinpatientswithprivateinsurance.9ThecesareansectionrateintheUS,whencomparedwiththatin
otherdevelopedcountries,istheamongthehighestintheworld.9, 10
AnanalysisofcesareandeliveriesattheUniversityofVermontbyPollardandCapelessin1995revealed
thattheprimarycesareansectionratewas11.4%.11Dystocia(arrestofdilatationordescent)accounted
forover35%ofcesareansectionsandtogetherwithabnormalpresentationwerethemajorindicationsfor
abdominaldelivery.Asignificantprobleminanalysesofindicationsforcesareansectionisthatdiagnoses
suchasdystocia,cephalopelvicdisproportion,andfailuretoprogressareinherentlyvagueanddonot
reflectthetruereasonwhythelaborisnotprogressingasanticipated.Anaccurateunderstandingand
recordingofthereasonthatlaborhasnotprogressed,includingthefetalsizeandposition,thestrength
andfrequencyoftheuterinecontractions,andtheadequacyofthematernalpelviswouldhelp.Itis
noteworthythatprimarycesareansectionsfordystociapredominateinfirstlaborsandarearelatively
uncommoneventinsubsequentlabors12andalsothatthemajorityofrepeatcesareanoperationsresult
fromwomenwhohavehadaprimarycesareandeliveryfordystocia.12Thereforecriticalevaluationof
patientswithevidenceofdystociaintheirfirstlabor,withidentificationandalleviationofcorrectable
problems,couldsignificantlyimpactonoverallcesareansectionrates.
Fetalmalpresentationcurrentlyaccountsforapproximately34%ofcesareansectionsintheUS.12
BecauseoftheInternationalTermBreechTrial,cesareansectionisroutinelyofferedtononvertexinfants
ifexternalcephalicversioniscontraindicatedorunsuccessful.13, 14, 15, 16
SimilarfindingswerepublishedintheUKNationalSentinelCesareanSectionAuditcommissionedbythe
UKDepartmentofHealth.17 Dataon99%ofbirthsthattookplaceinEngland,WalesandNorthern
Irelandovera3monthperiodin2000wereanalyzedandthemainreasonsforcesareansection
identifiedbythisauditareillustratedinTable2.
Table2Reasonsforcesareansection(CS)in2000intheUK17
OfallCSintheUK
Repeatcesarean
29
Presumedfetaldistress
22
Failuretoprogress
20
Breechbirth
16
Maternalrequest
1.5
InfluenceofmaternalageonCS
Maternalage<20years
13
Maternalage>40years
33
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Thestudiesaboveconcludethatrepeatcesareandeliveryandfailureoflaborprogressionarethemost
commoncausesbehindthehighratesofthisoperationinboththeUKandNorthAmerica.Fetaldistress
wasalsoasignificantcontributorintheUK(22%),possiblybecauseofthemethodsadoptedtodiagnose
fetalcompromiseduringlabor.Ontheotherhand,intheUS,fetalintoleranceoflaborcontributes
minimallytotheoverallcesareanrate.However,andgenerallyspeaking,thecesareansectionratehas
increasedwiththewidespreaduseofelectronicfetalmonitoring.18, 19, 20, 21, 22Theuseofcentralized
fetalmonitoringincreasesthecesareanrateevenmore.22Becauseofthewelldocumentedlowspecificity
ofanonreassuringfetalheartratepattern,furtherassessmentbyotherdiagnosticmeansshouldbe
undertakeninallbutthemostpressingcases.Recentlyfetalelectrocardiogram(ECG)recordingusinga
scalpelectrode(withanalysisoftheSTsegment,calledSTAN)hasbeenusedincombinationwith
cardiotocograph(CTG)recordingforintrapartumfetalmonitoringinEurope,becauseinitialtrials
suggestedthatitmightreducetheneedforfetalbloodsamplingandreducethenumberofbabies
deliveredwithametabolicacidosis,23butitisnotwithoutproblems24anditsvalueisstillbeing
assessed.25Anumberofotherprogramshavebeenimplementedatvariousinstitutionsinanattemptto
reducethecesareansectionrate.
IntheUSalaboradjustedcesareanratehasbeenproposedasamoreaccurateindicatorofthe
appropriatenessoftherateofcesareansectionthanrawnumbersandrates.26Thislaboradjustedrate
excludespatientswhoaredeterminednottobecandidatesforvaginaldeliverybyareasonablephysician
standard.Forexample,excludedpatientswouldincludewomenwithahistoryofclassicalcesarean
section,provenpelvicinadequacy,invasivecervicalmalignancy,suspectedruptureduterusbeforelabor,
maternaldiseasethatmaybelifethreateningbecauseofthephysiologicchangesinvolvedinlabor,
macrosomia,macrocephaly,monoamniotictwins,andnonreassuringfetalheartrateonantenatal
surveillance.Inonepopulationinwhichthelaboradjustedratewasstudied,theadjustedcesareanrate
wasalmostonethirdoftherawcesareanrate.
CLASSIFICATIONANDINDICATIONS
Traditionally,cesareansectionhasbeenclassifiedasemergencyorelective.However,withadvanced
practiceinobstetrics,andmorecomplicateddeliveriesencountered,thisdefinitionhasbecometoo
simplisticandmoredetailedcategoriesareneeded.Therefore,distinguishingbetweenprelaborcesarean
section(whichmaybeelectiveoremergency)andintrapartumcesareandelivery(whichis,bydefault,
emergency)ispreferable27 (Table3).Classificationoftheurgencyofcesareandeliveryhasalsobeen
investigatedbyLucasandcolleagues28andthishasdevelopedintothemostconsistentmethod
recommendedbyNCEPOD29andapprovedbytheRoyalCollegeofObstetriciansandGynaecologists
(RCOG)andtheRoyalCollegeofAnaesthetists(RCA)intheUK.
Table3Classificationofurgencyofcesareansection27 , 28
Classification
Indication
Grade1:Emergency
cesareansection
Immediatethreattothelifeofthewomanorthefetus,i.e.placental
abruption:antepartumoruterinerupture:intrapartum
Grade2:Urgent
cesareansection
Noimmediaterisktothelifeofthewomanorbabybutdeliveryshouldbe
achievedassoonaspossible,i.e.threepreviouscesareansections,
membranesarerupturedwithmeconiumstainedliquor:antepartumor
nonreassuringCTGandFBSisnotpossibleorcontraindicated:intrapartum
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Grade3:Nonscheduled Deliveryisneededbutcanfitinwithdeliverysuiteworkloadandallowfor
fasting/steroidadministrationandsomedegreeofplanning,i.e.preterm
IUGR/PET
Grade4:Scheduled
Alsoreferredtoaselective.Nourgencywhatsoever,andprocedureplanned
tosuitwoman,staff,deliverysuite,etc.andcarriedout>39weeksgestation
duringtheworkingday(i.e.notoutofhours)
CTG,cardiotocographFBS,fetalbloodsampleIUGR,intrauterinegrowthretardationPET,pre
eclamptictoxemia
Therefore,prelaborcesareansectioncouldbeanyofthefourcategoriesexplained,whilstintrapartum
cesareanwillonlyinvolvegrades1and2.
Indicationsforcesareandeliveryvarydependingontheclinicalsituation,resourcesavailableforpatient
care,andindividualphysicianmanagementtechniques.Therearenodefinitivealgorithmsavailabletothe
practicingobstetriciantodirectwhenanabdominaldeliverywillbenefitthemotherand/orthefetusin
everyclinicalsituation.Thedecisiontoperformanabdominaldeliveryremainsajointjudgmentbetween
thephysicianandpatientaftercarefullyweighingtheprosandconsofacesareandeliveryversus
continuedlaborand/oroperativeorspontaneousvaginaldelivery.Indicationsforcesareandeliverycan
bedividedintoindicationsthatareofbenefittothemother,thefetus,orbothasillustratedinTable4.30
Table4Indicationsforcesareansection30
Indications
Examples
Maternal
Absolute:
Morethan2previouscesareansections
Obstructivelesionsinthelowergenitaltractincludingmalignancies,and
leiomyomasoftheloweruterinesegmentthatinterferewithengagementof
thefetalhead
Relative:
Previousuterinesurgery:myomectomyorhysterotomy
Situationswheretheincreasingintrathoracicpressuregeneratedby
Valsalvamaneuverscouldleadtomaternalcomplications.Theseinclude,
dilatedaorticvalverootandrecentretinaldetachment.
Womenwithapriorvaginalorperinealreparativesurgery,suchas
colporrhaphyilealpouchanalanastomosisfollowingcolectomyfor
inflammatoryboweldisease
Fetal
Abnormalliesornonvertexpresentations
Multiplepregnancies:thefirsttwininanonvertexpresentation,or
higherordermultiples(tripletsorgreater)
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Somecongenitalanomalies
Fetalcompromise
Maternalinfection:primarygenitalherpes,HIV
Maternalfetal
Placentaprevia
Obstructedlabor
Indicationsforcesareandeliveryformaternalbenefitincludeanysituationinwhichitisinadvisableto
continuetostriveforavaginaldeliveryoutofconcernformaternaloutcome.Inthesesituations,the
womanundergoesamajorabdominaloperationforindicationsthatarelikelytodecreaseherriskfor
morbidityand/ormortality.Incontrast,whenacesareansectionisperformedforfetalindications,the
motherisundergoingmajorabdominalsurgerywhenthereisnoimmediatebenefittoherbutthereis
potentialbenefittotheneonate.Inthesesituations,fetalhealthwouldbecompromisediffurtherefforts
towardvaginaldeliverywerepursued.Whencounselingthepatientbeforecesareansectionregardingthe
risksandbenefitsofabdominaldelivery,thepossibilityofmorbidityandmortalitymustbediscussed.
Beforeperforminganelectiverepeatcesareandelivery,severalconsiderationsmustbeaddressed.In
1995,theACOGCommitteeonQualityAssessmentpublishedacriteriasetoutliningtheseconsiderations.
Thecommitteesuggestedthatthetypeofpreviousuterineincisionshouldbedocumentedfromthe
previousoperativenotes,therisksandbenefitsofattemptingavaginalbirthafteracesareansection
(VBAC)shouldbethoroughlydiscussedwiththepatientanddocumentedinthechart,therisksand
benefitsofrepeatcesareandeliveryshouldbethoroughlydiscussedwiththepatientanddocumentedin
thechart,andfetalmaturityshouldbeconsidered.31
FetallungmaturityisanimportantfactortobeconsideredbeforeattemptinganyprelaborelectiveCS.
Morrisonetal.(1995)conductedastudyon33,289deliveriesoccurringatorafter37weeksofgestation
andover9years.Theaimwastoestablishwhetherthetimingofdeliverybetween37and42weeks
gestationinfluencesneonatalrespiratoryoutcomeandthusprovideinformationwhichcanbeusedtoaid
planningofelectivedeliveryatterm.Theyfoundasignificantreductioninneonatalrespiratorymorbidity
wouldbeobtainedifelectivecesareansectionwasperformedintheweek39+0to39+6ofpregnancy.32A
morerecentstudyfromtheUSAhasmirroredthesefindings33andprelaborelectiveproceduresshould
bedeferreduntilafter39completedweeks.
TECHNIQUE
Asnotedinthehistoricalreviewatthebeginningofthischapter,thecesareanoperationhasundergonea
numberoftechnicalchangesastheprocedurehasevolved.Manydifferentpractitionersextolthebenefits
ofvarioustechniquesofskinincision,uterineincision,uterineclosure,andmanyothertechnicalaspects
oftheoperation.However,therearerelativelyfewrandomizedtrialstosupportmanyofthecommonly
usedpracticesatcesareansection.
Preoperativeevaluation
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Inthecaseofaplannedprocedure,thepreoperativeassessmentshouldincludeafullhistoryandphysical
examination,pastmedicalandsurgicalhistory,currentmedications,drugallergies,consent,and
indicationforcesareansection.Intheuncomplicatedpatientcheckingafullbloodcountandhavingserum
inthelaboratoryusuallysufficeshouldbloodtransfusionbecomenecessary.Inmorecomplexinstances
preoperativeconsultationwithananesthetist,orotherrelevantspecialistshouldbeconsideredonan
individualbasis.Theobstetricianshouldusuallyhighlightwomenwhoareathighriskofanesthetic
complicationsduringtheantenatalperiod.Therisksshouldbedocumentedinthemedicalnotesand
communicatedwiththeanesthetistnearerthetime.Theformofanesthetictobeusedwillbediscussed
anddecidedonbytheanesthetistwhoisalsoresponsiblefordiscussingallanestheticrisksand
complications.27
Converselyincasesofanemergencycesareansection,oncethedecisiontooperatehasbeenmadebythe
obstetrician,discussionwiththepatient,consentandpreoperativepreparationshouldbecarriedoutas
bestascircumstancesallow.27
Inveryhighriskcases,suchasplacentapreviaorsuspectedaccreta,otherpreoperativemeasuresshould
alsobeconsidered:27 theseincludethepresenceofaseniorobstetricianandanesthetistatthetimeofthe
operationitmaybenecessarytoinvolveinterventionalradiologistsandacellsavermaybemade
available.Mostimportantly,thewomanshouldhavebeenfullycounseledandconsentedforthedifferent
treatmentoptionsincludingthepossibilityofhysterectomyinextremecircumstances.Protocolsshould
bepresentoneverydeliverysuitefortheeventofmassiveobstetrichemorrhage
Consent
Thepersonperformingtheprocedureisresponsibleforcheckingthatwritteninformedconsenthasbeen
given.He/sheshouldexplainthereasonswhythisoperationisneeded.Associatedrisksand
complicationsshouldbeclearlycommunicatedwiththepatientandcaremustbetakenwhenexplaining
thefrequentlyoccurringcomplicationsandthosethatarelesslikelybutserious.Theimportanceofgood
communicationisessentialandhasbeenhighlightedinthereportSaferChildbirth.34
Abdominalpreparation
Thereisevidencethatanyabdominalshaveperformedshouldbeperformedintheoperatingroomjust
beforeapplyingtheantibacterialpreparationsandnotthenightbefore.Shavingthepatientthenight
beforesurgeryactuallyincreasesthebacterialcountonthematernalabdomen.35Shavingshouldbe
performedonlytoremovethehairthatwillphysicallyinterferewiththeoperationitself.
Patientpreparation
Placingthepatientintheleftlateraltiltpositionusingeitherahipwedgeoranoperativetablewithlateral
tiltcapabilitywillhelpminimiseuterinecompressionoftheinferiorvenacava.Beforetheabdominal
preparationanddrapingofthepatient,aFoleycathetershouldbeplacedtoallowthebladdertodrain
duringtheoperationkeepingtheoperativefieldclearandallowingurinaryoutputtobeevaluated
intraoperatively.
Surgicalprinciples
Anykindofsurgeryshouldbecarriedoutwithadequatebutnotexcessiveaccess.Gentlehandlingand
respectoftissues,togetherwithmeticulousattentiontohemostasisareessentialandimportantfactorsin
allaspectsofsurgery.Anatomicalknowledgeshouldbethoroughinordertoavoidunplanneddamage,
especiallywhenpathologyisencountered.27
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Skinincision
Theskinincisionshouldbemadeinonesweepingmotionusingthebellyofthescalpel.Itshouldbeofan
adequatesizetogivesufficientaccessandisusuallyabout12cmlong.27 Anumberofskinincisionshave
beenusedinabdominaldeliveries(Fig.2):twolowerabdominal(PfannenstielandJoelCohen)andone
midlinevertical.Historically,averticalmidlineskinincisionwasimplemented,however,thisscaris
cosmeticallylessacceptableandisassociatedwithhigherincidenceofpostoperativewounddiscomfort,
dehiscence,infection,andherniaformation.Itmaystillbenecessaryifaccessisrequiredtotheupper
uterusortootherabdominalorgans.Atpresent,themostfrequentlyusedtypeofskinincisionisthe
Pfannenstielincision.Ingeneral,theskinincisionshouldbedeterminedbythephysicianbasedonthe
clinicalsituationandtheskillofthesurgeon.Transverseincisionsfallalongthelinesofexpressionofthe
anteriorabdominalwallandthereforeshouldcreatelesspronouncedscarringandriskofdehiscence.
Transverseincisionshavealsobeenassociatedwithlesspostoperativepain.Midlineverticalincisionsare
generallymorehemostaticandrequirelessdissectiontherefore,lesstimefromincisiontobirththan
transverseincisions.36
(http://resources.ama.uk.com/glowm_www/graphics/figures/v2/0740/003f.jpg)Fig.2.Abdominal
incisions.A.Pfannenstielincisionshouldbemadeinacurvilinearfashionapproximately23cmabove
thepubicsymphysis.B.JoelCohenincisionshouldbemadeinalinearfashionapproximately23cm
abovethetraditionalplacementofthePfannenstielincision.C.Midlineverticalincisionshouldbe
madeinthemidlineandextendfromjustbelowtheumbilicustojustabovethesymphysispubisand
maybecontinuedaroundtheumbilicusifmoreexposureisnecessary.
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TRANSVERSEINCISIONS
ThePfannenstielincisionismadetransverselyinthematernalabdomenapproximately23cmabovethe
symphysispubisandiscurvilinear,withthelateralapicesoftheincisionsmilinguptowardtheanterior
superioriliacspines(Fig.3).Thisincisionisperformedsharplytotheleveloftheanteriorrectusfascia
whichisthensharplyincisedwiththescalpelinatransversemannerinthemidlinetoexposethebellyof
therectusmuscleoneithersideofthemidline.Atthistime,theincisionintheanteriorrectusfasciamay
beextendedlaterallyusingeitherthescalpelorMayoscissors.Extendingthisincisionlaterallythrough
thesubcutaneoustissuerisksdamagetothesuperficialepigastricandsuperficialcircumflexiliacveins,
respectivelyattentiontohemostasisisthereforeimportanttominimizetheriskofhematomaformation.
Careshouldbetakentoavoidcuttingthetransverseobliquemusclewhenincisingthefascia.Afterthe
fasciaisincised,theanteriorrectusfasciacanthenbedissectedfromtheunderlyingrectusmusclesin
boththecephalicand(ifneeded)caudaldirectionsbyacombinationofbluntandsharpdissection.During
thisdissection,caremustbetakentoidentifyandligateorelectrocoagulatetheperforatingvessels
betweentherectusmusclesandtheanteriorfasciathiscanbeperformedatentry,orintheeventofan
emergencycesareandelivery,atthetimeofclosure.Oncethesheathhasbeenmobilizedtheperitoneum
shouldbeexposedstayinginthemidline(avoidhookingfingersundertherectusmusclewhichcan
damagetheinferiorepigastricvascularbundle).Thentheentrypointthroughtheperitoneumshouldbe
madehighintheoperativefieldtoavoidinjurytothematernalbladderusingsharporbluntdissection:
elevatingtheperitonealmembranebetweentwohemostatsandpalpatingtheopposingpiecesof
membranetoexcludeentrappedbowelthenincisingwithascalpelorpushingafingerthroughthe
peritoneum.Oncetheperitonealcavityisenteredandacheckhasbeenmadetoexcludeordivide
adhesions,theperitonealincisionisextendedeitherbluntlyorusingscissors,tomaximizesurgical
exposure,withcarebeingtakentoavoidinadvertentdamage.
TheJoelCohenincisionisperformedinatransversemannerabovethelocationofaPfannenstielincision
andislinear,notcurvilinear.Oncethefasciaisincisedtherestofthedissectionisperformedbluntly.An
advantageofthistypeofincisionisspeedhowever,therearenomaternalorfetaladvantagesotherthan
this.37 , 38
Inthemoderatelyobesepatient,avariationofthePfannenstielincisionisperformedafewcentimeters
higherthanthetruePfannenstieltoavoidplacingtheincisioninthefoldcreatedbytheabdominalpannus
andtherebydecreasingtherateofwoundcomplications.
VERTICALINCISIONS
Historically,themidlineverticalskinincisionwasthepreferredincisionforcesareansectionbecauseof
thespeedandeaseofentryintotheperitonealcavitywithminimaldissectionrequired.Verticalincisions
remainusefulinsituationswhereaccesshighontheuterusisneeded.Theincisionisperformedvertically
fromjustbelowtheumbilicusandextendedtojustabovethesymphysispubisandcaneasilybeextended
aroundtheumbilicusifexposureoftheupperabdomenisrequired.Whenmakingamidlinevertical
incision,itisimportanttorememberthatthelineanigramaynotrepresentthetruemidline.Theincision
iscarriedsharplydowntotheleveloftherectussheath,whichisthencarefullyincisedwiththescalpelina
verticaldirection.ThisincisionmaybecompletedwiththescalpelorbyusingtheMayoscissors.The
fascialedgeclosesttothemidlineisthengraspedwithapairofsmallclamps,andsharpandblunt
dissectionsareusedtoseparatetherectusmusclesandallowentrythroughtheperitoneumverticallyas
describedpreviously.
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Inpatientsundergoingrepeatcesareandelivery,theabdominalscarmayberevisedatthetimeofrepeat
operation.Inthecaseofanemergencycesareansection,scarrevisioncanbeperformedatthetimeof
abdominalclosure.Itisalsoimportanttorememberthatthechoiceofskinincisionshouldbethatwhich
theprimarysurgeonbelieveswillbemostbeneficialforthepresentoperationandshouldnotbedictated
bythelocationofapreviousscar.Hypertrophicscarsarebestexcisedasthisgivesabettercosmeticresult
andisassociatedwithimprovedwoundhealinghowever,iftheoldscariskeloidthenitsmarginsshould
beleft,asthisgenerateslesstissuereactioninthesubsequentscar.27
Exposureandaccesstotheuterus
Therearethreestandarduterineincisionsthatcanbeperformedfordeliveryofthefetus:lowtransverse,
lowvertical,andclassical(Fig.3).Thespecifictypeofuterineincisionshouldbedeterminedbythe
primarysurgeonatthetimeoftheoperationbasedongestationalageandlieofthefetusandanyuterine
anomalies.Oneoftheimportantfactorstobeassessedbeforeincisingtheuterusisthewidthofthelower
segment(thedistancebetweenthebroadligaments).Thisshouldbeassessedinrelationtothesizeofthe
babytodecidewhetheratransverseorlongitudinalincisionismostappropriate.Ineithercase,the
peritoneumneedstobereflectedinferiorlybeforetheuterineincisionismade.27
(http://resources.ama.uk.com/glowm_www/graphics/figures/v2/0740/004f.jpg)Fig.3.Uterineincisions.
A.Lowtransverseuterineincisionshouldbemadethroughthethin,noncontractileportionofthe
loweruterinesegmentinacurvilinearfashion.Alsopicturedisalowverticalincision,whichismade
throughthenoncontractileloweruterinesegmentinaverticalfashion.B.Jextensionofthelow
transverseincision.Whenadditionalexposuretotheuterinecavityisrequiredtodeliverthefetus,the
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lowtransverseincisioncanbeextendedlaterallyandcephaladtoincreasethelengthoftheincision
withoutendangeringtheuterinearteries.C.AnotheroptioninthissituationistouseaTextensionin
themidline.D.Theclassicaluterineincisionismadethroughthecontractileportionofthe
myometriumabovethebladderreflection.
Historically,thecreationofabladderflapwasadvocatedbeforemakinganyuterineincisions.More
recently,randomizedcontrolledtrialshavenotedthattheomissionofthebladderflapprovidesshort
termadvantagessuchasreductionofoperatingtimeandincisiondeliveryinterval,reducedbloodloss
andneedforanalgesics.Practicallyspeakingadequateaccesstothelowersegmentmayrequiresome
dissectionbutthisshouldbekepttowhatisneededandnotbeexcessive.Theperitoneumisgraspedwith
apairofforceps,elevated,andthenincisedtransverselywithscissors.Next,theinferiorportionofthe
peritoneumiselevatedfromtheloweruterinesegment.ADoynesretractorshouldthenbeinsertedto
keepthebladderclearofthesurgicalfield.Beforemakingtheuterineincision,thesurgeonshouldalso
identifytheroundligamentstoassessthedegreeofdextrarotationoftheuterusandtoevaluateforthe
presenceofanymyomasorothermalformationsthatmightaffectthechoiceand/orplacementofthe
incision.
Loweruterinesegmentincision
Thestandardlowsegmenttransverseincisionaccountsfor90%ofalluterineincisions.17 Thisincision
shouldbemade23cmbelowtheupperedgeoftheuterovesicalfoldofperitoneum.Thisisespecially
importantwhenthecesareanisperformedatornearfulldilatation,asthetendencyistogointoolow,
duetothestretchedandballoonedoutlowersegment.Alowentryinthissituationrisksextensionofthe
uterineanglesintothebroadligament,orevenmoredangerouslyitcanriskentryintothevagina
(inadvertentlaparoelytrotomy)bothcomplicationscarryattendantriskstotheureters.Theincisionis
thenmadesharplywiththescalpelinthemidlineandperformeddowntothelevelofthefetal
membranes,withcarebeingmadenottoincisethemembranes,andextendedlaterallyusingeitherblunt
dissectionwiththefingersorscissors(Fig.4).Itisbesttotrytoleavethemembranesintactatthisstagein
ordertoavoidtheriskofcuttingthebabyandtomaintaintheliquoruntiltheuterineincisionis
completed(particularattentiontoavoidcuttingthebabyisnecessarywherethemembraneshavealready
ruptured,incasesofoligohydramnios,breechpresentations,advancedlabororafterrepeatcesarean,
wherethelowersegmentcanbeverythin).27 Therewasthoughttobenodifferencebetweenthetwo
methodsofextendingtheuterineincisioninamountofbloodlostorintherateofextensionofthe
incisionintothelateraluterinevesselswhentheywerecomparedandcorrelatedbythestageoflabor.39
However,arecentinvestigationrevealedagreaterriskofsubsequentbloodtransfusioninwomenwhose
incisionwasextendedsharplycomparedtothoseextendedbluntly.40Whenbluntdissectionisused,an
upwardcurveoftheincisionmaybecreatedbythesurgeonsplacingtheirthumbsonthepatient's
anteriorsuperioriliacspinesandindexfingersintheuterineincision.Bykeepingthehandinthis
position,theincisionispulledopeninanarc.
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(http://resources.ama.uk.com/glowm_www/graphics/figures/v2/0740/005f.jpg)Fig.4.Extensionofthe
loweruterineincisionmaybeaccomplishedbyeitherinsertingfingersintotheuterinecavityand
bluntlystretchingthemyometrialincisioninacurvilinearfashionorsharplycuttingtheloweruterine
segmentwithbandagescissors.Whentheuterushasapoorlydevelopedloweruterinesegment,using
bandagescissorsisoftenpreferable.
Intentionalextensionofthelowtransverseincisionisnecessaryin12%ofcases.40Typically,the
extensionofthelowtransverseincisionisperformedbycreatingalowverticalincisioninthemidline,T
extensionoftheuterineincision,orcreatingaverticalincisionatthelateralaspectoftheuterineincision,
aJextension.Theseextensionsarecommonlyperformedformalpresentations,poorlydevelopedlower
uterinesegment,ordeeptransversearrest.40Whenperformed,extensionsofthelowtransverseincision
areassociatedwithincreasedincidenceofmaternalbloodloss,broadligamenthematoma,anduterine
arterylacerationcomparedwithlowsegmenttransverseincisionsthatdonotrequireextension.
Thelowverticaluterineincisionismadeparalleltothelongitudinalaxisoftheuterusinthemidline,with
carebeingtakentoremainbelowthecontractileportionoftheuterusandwithinthethinloweruterine
segment.Otherthanthedirectionoftheincision,technicalaspectsarecarriedoutasdescribedforthe
lowtransverseuterineincision.Studieshaveshownthatthereisnoincreasedriskofuterinerupturein
patientswiththistypeofincisioncomparedwiththelowsegmenttransverseincisionaslongasthe
incisionremainsprimarilyinthethinloweruterinesegment.41
Placentaprevia
Placentapreviacanbeassociatedwithheavybloodloss,anditisimportantthataseniordoctorispresent
atdelivery.Assessmentoftheplacentalsiteandcordinsertionbyultrasoundscanpriortotheoperation
ishelpfulinplanningthesurgicalapproachonreachingtheplacenta:bluntdissectionshouldfollow
preferablygentlypushingtheplacentaasidetoaccessthemembranes,butitmayhavetobeentered
digitallyandthecordinsertionshouldbeavoidedandthecordclampedquicklyafterdeliveryofthe
baby.27
Upperuterinesegmentincision
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Aclassicaluterineincisionismadebyincisingtheuterusparalleltothelongitudinalaxisoftheuterus
throughthecontractileportionofthemyometrium.Indicationsforclassicaluterineincisioninclude
situationsinwhichtheloweruterinesegmentisnotadequatelydevelopedtoaccommodatealow
transverseoralowverticalincisioncasesofabnormalfetalliesuchasbackdowntransverselie,inwhich
thelowtransverseorlowverticalincisionwillnotallowtheoperatoradequateaccesstothefetusfor
manipulationanddelivery,orwhenmyomasoruterineabnormalitiesdistorttheuterusinsuchawayas
tomakealowtransverseincisioninadvisable.
Deliveryofthefetuscephalicpresentation
Aftertheuterineincisionhasbeenmade,thefetalmembranes,ifstillintact,arerupturedcarefully.Ifthe
fetusisinanoncephalicpresentation,leavingthemembranesintactuntilthefetalfeetorheadcanbe
movedintotheuterineincisionwillincreasetheeaseofdelivery.Whenthefetusisinacephalic
presentation,deliveryisperformedbythesurgeonsplacingtheirdominanthandintotheloweruterine
cavityandelevatingthefetalheadintotheuterineincision(Fig.5).TheDoyenretractorshouldthenbe
removed.Ifthefetusisnotinanoccipitotransverseposition,rotatingtheheadintothispositionwill
allowthefetalnecktoflexlaterallyaroundtheupperportionoftheincisedmyometriumanddeliverinto
thewoundwiththeaidoffundalpressure.Eachshouldershouldbegentlydeliveredinturnfollowedby
thetrunkofthebaby.Facilitatingthedeliverybytheassistantusingfundalpressureisimportantasthe
operatorshouldapplyminimaltractiontothebabysheadneckandbrachialplexusinjuriesarenot
confinedtooverzealoustractionatvaginaldeliveries.27 Iftheheadishighanddeliveryisdifficult,the
WrigleysforcepsorKiwiventousecupcanbeappliedtogentlyguideoutthebabyshead.Whenthefetal
headisimpactedinthematernalpelvis,suchasindeeptransversearrestorcesareanatfulldilatation,
thereareanumberofoptionstoassistwithdeliveryofthefetalhead.Thesurgeoncanplaceahandinthe
loweruterinesegmentinthestandardfashiontocuptheheadandwaituntiltheuterusrelaxesbefore
tryingtodisengageit.Tryingtodisimpacttheheadwhilsttheuterusiscontractingisunlikelytowork,will
riskextensionoftheuterineangles,willpromotecontinueduterinetone,andmaycausefetaltrauma.If
waitingdoesnothelp,theanesthetistscanrelaxtheuterususingatocolyticsuchasterbutalineorglyceryl
trinitrateGTN.Ifthisdoesnotwork,anassistantcanplaceasterile,glovedhandintothevaginafromthe
introitusanddisengagethefetalheadfrombelowbutagainthisshouldnotbeperformedwhiletheuterus
iscontracting(Fig.6).
(http://resources.ama.uk.com/glowm_www/graphics/figures/v2/0740/006f.jpg)
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Fig.5.Extractionofthefetalhead.Thesurgeon'sdominanthandisplacedintotheuterineincisionso
thatthebackofthehandisagainsttheinsideoftheloweruterinesegmentandthefingerscupthefetal
head.Firm,gentletractionisusedtoelevatethefetalheadtowardtheincision.Thefetalheadmay
thenberotatedtoanocciputanteriorpositionanddeliveredthroughtheuterineincisionwiththe
assistanceoffundalpressure.CourtesyofRPrestonMcGeheeMD.
(http://resources.ama.uk.com/glowm_www/graphics/figures/v2/0740/007f.jpg)Fig.6.Disimpactionof
thefetalhead.Whenthefetalheadhasdescendedsofarintothevaginathatextractionofthefetal
headisdifficult,havinganassistantplaceaglovedhandintothevaginaandelevatethefetalheadfrom
belowcanincreasetheeaseofdeliveryanddecreasethetraumatotheloweruterinesegmentand
vagina.
Aftertheinfantisdelivered,itshouldbequicklydriedandthenafterashorttimethecordshouldbe
doublyclampedandcut.Dependingontheconditionoftheinfantitcaneitherbehandedstraighttoits
motherforskinskincontact,or,ifneededitcanbehandedtotherelevantpersonnelwhohavebeen
assignedtocareforthenewborn.Thebabyshouldnotbeliftedupbeforethecordisclamped,andatime
delaytoclampingthecordofaboutaminute,toallowfetaltransfusion,shouldbefacilitatedwhere
possible.
Deliveryofthefetusbreechpresentationandtransverselies
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Inbreechcesarean,ifthelegsareextendedtheoperatorsrighthandshouldbecuppedaroundthe
bottomandthebreechdeliveredbylateralflexionwhiletheassistantexertsfundalpressure.
Alternatively,afoot(recognizedbytheheel)canbeheldandthelegsdeliveredfirst.Ineithersituation
thefetalbackshouldbekeptanterior,andcompletionofthedeliveryisagainachievedbyfundalpressure
withminimaltraction:asinthevaginalbreechdelivery,theshouldersshouldbedeliveredwithgentle
rotation,andamodifiedMaurcieuSmellieVeittechniquecanthenbeusedtofacilitatedeliveryofthe
head.27 Ifthebabyistransverse,afootshouldbeidentifiedandthebabydeliveredasbreech.Inthis
circumstance,leavingthemembranesintactforaslongaspossiblewillfacilitatetheinternalrotationof
thebaby.
Deliveryoftheplacenta
Attentionisnowturnedtothedeliveryoftheplacenta.Spontaneousdeliveryoftheplacenta,when
assistedwithuterinemassage,5IUofintravenousoxytocinandgentletractionontheumbilicalcord,is
associatedwithalowerrateofpostpartumendomyometritisandmaternalbloodlosscomparedwith
manualextraction.42, 43, 44Infrequently,theplacentadoesnotseparatedespitetheuterusbeingwell
contractedandmanualremovalisrequired.Manualremovalcarrieshigherrisksofhemorrhageand
infection,andthereforetheoperatorshouldguardagainstimpatienceandcertainlynotperformmanual
removalwhiletheuterusisnotcontracting,asthiswillincreasebloodlossconsiderably.Anybleeding
sinusesontheuteruscanbecompressedusingGreenArmitageclampswhileawaitingplacental
separation.Incasesofmorbidlyadherentplacenta(placentaaccreta),thereareseveralmanagement
options:first,iftheplacentahasnotbeenbreachedduringuterineentryanddeliveryofthebabyandno
placentalseparationhasoccurred,theplacentamayeitherbeleftinsituandthepatientmanaged
conservatively,or,second,ahysterectomymaybepreferred(dependingonthepreoperativediscussion
withandconsentbythepatient).
Oncetheplacentahasbeendelivered,theuterinecavityshouldbecheckedtoensureitisemptyandthe
uterusmaybeeitherexteriorizedorleftinsitutoberepaired.Bloodlossisnotsignificantlydifferentwith
eithermethod.45Exteriorizationoftheuterusdoesallowforbettervisualizationoftheadnexal
structuresandincreasestheeasewithwhichtuballigationcanbeperformedbutproducesmore
discomfortinwomenhavingregionalblockade.45
Abroadspectrumantibioticsuchascoamoxiclav1.2gor,ifpenicillinallergic,clindamycin600mg
intravenouslyshouldbegiventoallwomenatthetimeofcesareansectionafterdeliveryofthebabyand
placenta.Ifthereisextensivehemorrhagefromtheplacentalbedaftertheplacentahasbeenremoved,a
numberoftechniquescanbeusedtohelpcontrolthebleeding,theseincludelocalinfiltrationwith
uterotonics,underrunningthebleedingareaswithsutures,localpressurewithaRuschballoon,or
embolizationbyinterventionradiology.IfthebleedingisduetoatonythenaBLynchcompressionsuture
mayhelp.Hysterectomyremainsanoptionincaseoffailureoftheselattermeasuresorwithcatastrophic
bleeding.
Uterineclosure
Closingtheuterusaftercesareansectionisbestperformedwithadoublelayertechnique.NICEsupports
thispractice46asstudieshavefoundafourtosixfoldincreaseintheriskofuterineruptureinwomen
whohadasinglelayerclosure(Fig.7)intheirpreviouspregnancy.47 , 48, 49, 50TherecentCAESARstudy
intheUKwhichcomparedsingleanddoubleclosuredidnotlookatlongtermoutcomes.51
Whethersingleordoublelayerclosureisused,suturematerialshouldbeofashorttermabsorbable
type52(suchaspolyglycolicacidorpolyglactin)astheuterusinvolutespostnatallyandsuturesloosen,to
avoidloopsofthreadbeingpresentinthepelvisforanylongerthannecessary.Bothuterineanglesshould
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beidentified,suturedandtiedsecurely.
(http://resources.ama.uk.com/glowm_www/graphics/figures/v2/0740/008f.jpg)Fig.7.Singlelayer
repairofthelowtransverseuterineincision.Toobtainoptimalhemostasisoftheincisioninasingle
layer,thesurgeonshouldbecarefultoincludealllayersofincisedmyometriumwhiletakingcareto
avoidincludingexcessdeciduaandserosa.CourtesyofRPrestonMcGeheeMD.
Fortwolayerclosurethefirstlayerincludesthedeepmyometrialedgewithminimaldecidua.A
continuouslockingtechniqueishemostaticandequallydistributesthetension,makingthesutureless
likelytocutthrough(especiallyusefulwithfriableorthinlowersegments).However,continuoussuturing
oftheuterusbeingmorehemostaticmayreducebloodsupply.53Thesecondlayercompletesthe
myometrialapproximationandhemostasis.Lockingthislayerisnotnecessarybutextrahemostatic
suturesmayberequiredifbleedingpersists.Thesecondlayereffectivelyburiesthefirstlayerbutthis
cosmeticeffectisnotitspurposewhichistomaintainthescarintegrityandpreventfuturedeficiency.A
firstlayerthatisclumsythickandincludinglargechunksofdeciduastendstopromotetheconceptthat
thesecondlayerisdesignedtohideitwhichisoftenachievedbypickingupadventitiafrombelowand
abovetheuterineincision.Suchtissueapproximationisillogical,cancausebleeding,andcanhitchthe
bladderuptowardstheincision,makingfuturesurgerymoretreacherous27 (Fig.8).
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(http://resources.ama.uk.com/glowm_www/uploads/1294479325_Ch_2.74_8Capture.JPG)Fig.8.
AdaptedfromStoryetal.,2009.Diagramillustratingthecorrectmethodforthetwolayerclosureof
theuterinelowersegmentcesareanincisionwithnodecidualinvolvement27
Decidualexclusionisveryimportantinordertoavoidendometrialinversionatthescarsite,asthisis
believedtobethecauseofincompletescarhealing.AlfredWainorek(1967)conductedastudytoexamine
therelationshipbetweentypeofscardeformityandthesuturingmethodused.Heperformed
hysterographicexaminationon270patientswhohadpreviouslyundergonecesareandelivery,and
evaluatedthescaronthebasisofdepth,shapeandsize.Heshowedthattheseverityofscardefectwasin
directproportiontothenumberofoperationsperformed.Hefounddyepenetrationdeepintothewallin
twocases,whereinboth,inclusionofthedeciduainthesuturematerialwasclearlyrecordedinthe
operativenotes.HeconcludedthatthebestXraypictureswithnovisiblescardefectwereobtainedwhen
interruptedsuturewasappliedthroughthemyometrium,andwhenthedecidualexclusionapproachwas
adopted.54
Classicaluterineincisionsaremuchthickerandtheyarenormallyrepairedinthreelayers.Theprinciple
torememberisthatthedeadspaceneedstobeobliteratedtoachievehemostasisandreducethechance
ofhematomaformation.Suturesshouldbeinterruptedandabsorbable.Thefinalsuturelayerisbest
achievedwithamonofilamentinertfinecontinuouslockingsuturetotheserosatominimizeadhesion
formation.
Aftertheuterusisclosedattentionshouldbeturnedtoensuringthattheoperativefieldishemostatic,
withspecialattentiongiventotheuterineangles,uterineincisionandtherawareaofperitonealreflection
belowtheincisionadjacenttothebladder.Theparacolicguttersshouldbecheckedandcleanedthetubes
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andovariesshouldbeidentifiedtoensurenormalanatomy.Hemostasisoftheperitonealedges,the
rectusmusclesandtheundersideofthesheathshouldthenbecheckedandsecuredbyeithersuture
ligationorelectrocoagulationofbleedingpoints.
Closinganddrains
Thereisnoadvantagetoclosureofthevisceralorparietalperitoneum,thishasalsobeenexaminedinthe
CAESARtrialandnosignificantdifferencewasfoundbetweenthetwoarms(closurevs.nonclosureofthe
peritoneum)intermsofmaternalinfectiousmorbidity.51Whenrepairedwithsuture,theperitoneum
undergoesmoreinflammationandscarringinanimalmodels.55Operatingtimeandpostoperative
analgesiarequirementsarereducedinpatientswhodonotundergoclosureofthevisceralandparietal
peritoneum.Thereisalsoadecreaseinadhesionsfoundatrepeatoperationwhenthevisceraland
parietalperitoneumisnotclosed.
TheuseofdrainshasalsobeenevaluatedbytheCAESARtrial51therewasahigherriskofmaternal
infectiousmorbidityassociatedwiththeliberalversusrestricteduseofsubrectussheathdrain(20.8%
versus15.6%).Ifadrainisneededintheperitonealcavity,asoftlargeborenonsuctioneddrainsuchasa
Robinsondrainissuitable.Ifthesheathrequiresdrainage,thenaRedivacdrainmaybeusedbutinsuch
casestheparietalperitoneumshouldbeclosedtoavoiddirectcommunicationofthesuctiondrainwith
theabdomencontents.27
FascialclosureinaPfannenstielincisionisperformedwithacontinuoussyntheticabsorbablestitch.In
patientswhohaveundergonemorethanonelaparotomythroughthesamescar,orinpatientswhoareat
increasedriskoffascialseparationordehiscencesuchasdiabeticpatientsorpatientswhoareon
corticosteroids,theuseofasyntheticdelayedabsorbablesuturesuchaspolydioxanone56orapermanent
monofilamentsuturesuchasprolenemaybepreferablebecauseofitsabilitytomaintainsuturestrength
foralongerperiodoftime.57 Fortheclosureofaverticalfascialincision,acontinuousunlockedrunning
delayedabsorbableorpermanentsutureshouldbeused.Wheneversuturesareplacedwithinthefascia,
theyneedtobesecurebutnotoverlytightasovertighteningcausespostoperativepain:reverselocking
oneortwosuturesatevendistancesacrossthewoundcanhelptodistributetension.Itisalsoimportant
torememberthata10mmzoneofcollagenolysisoccurssurroundingtheincisiontherefore,sutures
shouldbeplacedmorethan1cmfromthefascialedgetoachievemaximalwoundstrengthandtoavoid
herniaformation.58
Thesubcutaneoustissuemaybeclosedwithanabsorbablesutureinwomenwithmorethan2cmof
subcutaneousfatorifapreviousscarhasbeenexcisedinordertominimizetheriskofwoundhematoma
andinfection.27 Inslimmerpatients,closingthislayerhasnotbeenassociatedwithdecreasedratesof
superficialwounddisruptioninseveralstudies.59Thepointofthislayeristoclosethedeadspaceand
supporttheskinlayer,soScarpasfasciashouldbedeliberatelyincludedinit.27 Theskinshouldthenbe
closedwithasubcuticularstitch.Subcuticularstitcheshavebeenassociatedwithlessimmediate
postoperativepainandaremorecosmeticallyappealingat6weekswhencomparedtothestapling
device.59
Postoperativecare
Thereislittleliteraturetosupportanyspecificpostoperativeregimeninpostcesareanpatientshowever,
commonsenseandextrapolationofdatafromotherpostlaparotomypatientsallowforthedevelopment
ofarationalplanofcare.Mostcesareansectionsarerelativelyuncomplicated,andinthesepatients,care
shouldbegivenaccordingtotheneedsdictatedbythemethodofanesthesiaandanyobstetricormedical
complicationspresent,whilemaximizingnormality,skinskincontactofmotherandbabyandother
midwiferyissuessuchasinitiatingbreastfeeding.
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Inthefirsthourafteranuncomplicatedcesareansection,thepatientshouldbemonitoredcloselyina
recoveryareawhereurineoutput,pulse,bloodpressure,respirations,andanyevidenceofbleedingcan
becloselyobservedifthepatientremainsstableandwithoutcomplication,shemaythenbetransferred
tothepostpartumward.Onceanynauseahasabated,thepatientshouldbeencouragedtotakefluids
orallyandshecaneatwhenshefeelshungry.Earlyinstitutionoffeedinginthepostsurgicalpatientwith
minimalintraoperativebowelmanipulationdoesnotincreasetheincidenceofpostoperativeileus.60, 61
Allwomenshouldbegivencompressionstockingsandkeptwellhydratedaftercesareansectionto
minimizetheriskofthromboembolism.Heparinthromboprophylaxisshouldbegiveniftherearerisk
factorsandinaccordancewithlocalguidelines.Earlyambulationshouldalsobeencouraged.Gettingthe
patientoutofbedassoonasregionalanesthesiahaswornofforassoonasshehasrecoveredfrom
generalanesthesiawilldecreasetheincidenceofpulmonarycomplicationssuchasatelectasisand
pneumonia,andtheincidenceofthromboticcomplications.Encouragementofdeepbreathingand
coughingwillalsohelppreventcollapseofalveoliinthelungandsubsequentinfection.
Intheuncomplicatedpatientwithadequateurineoutput,thecathetershouldberemoved12hours
postoperativelyunlessthiswouldbeintheeveninginwhichcaseitshouldwaittoberemoveduntilthe
followingmorning.Encouragingmobilizationwillalsofacilitatetheremovalofbladdercatheters,
thereforedecreasingtheincidenceofcatheterassociatedurinarytractinfections.
Routinelaboratorystudiesareprobablyunnecessaryinmostpostcesareanpatientswhohaveno
unexpectedsymptoms.However,asinglehemoglobindeterminationonpostoperativeday2isprobably
reasonabletoscreenforsignificantanemia.Mostpostpartumpatientswithasymptomaticanemia
respondwelltooralirontherapy.
Thewoundshouldbecaredforinthestandardmanner,withocclusivedressingsremovedonthefirst
postoperativedayandthewoundexamineddailyduringthehospitalizationforevidenceofinfection,
seroma,orhematoma.Thepatientmaybedischargedwhensheisabletocareforherselfandher
newborn.Manypatientsarereadytoleavethehospitalbypostoperativeday2or3.Discharge
instructionsshouldincludepatienteducationconcerningexpectationsonactivitylevel,lochia,
breastfeedingormilksuppression,contraception,andnewborncare,andtheplansforsutureremoval.
SPECIALSITUATIONS
Vaginalbirthaftercesareansection
Thevaginalbirthaftercesareansection(VBAC)rateisdefinedasthenumberofvaginalbirthstowomen
withapreviouscesareansectionper100deliveriestowomenwhohadapreviouscesareandelivery.New
evidenceisemergingtostatethatVBACmaynotbeassafeasitsoriginallythought.62Inaddition,fearof
medicolegallitigationshaveledtoadeclineinthenumberofcliniciansofferingandwomenaccepting
plannedVBACintheUKandNorthAmerica.63Therearenorandomizedcontrolledtrialscomparing
plannedVBACwithplannedelectiverepeatcesareandelivery(ERCD)andthismaybeanunrealistic
aspiration.TheagencyforhealthqualityandresearchintheUSranksthecurrentavailableevidence
relatedtoVBACasleveltwoorthree,andacknowledgesconsiderableheterogeneityinthereported
outcomesandpoorcomparabilitybetweenthetreatmentgroups.
IntheUSAinthelateeightiesandninetiestherewasadrivetoincreaseVBACandtheraterosefrom6.6%
in1985to28.3%in1996,64butenthusiasmwanedascomplicationsaroseandby2006ithadfallentojust
under9%64(Fig.9)
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(http://resources.ama.uk.com/glowm_www/uploads/1294479574_Ch_2.74_9Capture.JPG)
Fig.9.RatesofVBACintheUS,1981200664
IntheUK,wenowhaveabetterideaoftheoverallVBACrate.TheNationalSentinelCesareanSection
AuditReport,October2001,foundthatofallmotherswhofellpregnantfollowingpreviouscesarean
section,33%achievedavaginaldelivery.Althoughthiscanseemlowwhensetagainstthe7085%VBAC
ratesfoundinmostresearchstudies,thesestudiesexploretheratesofsuccessinwomenwhoembarkon
attemptingVBACandinroutinecaremanywomenarenotofferedordeclinetheoptionofVBAC.17
SeveralauthorshaveattemptedtopredictwhichpatientsaremorelikelytoundergosuccessfulVBACby
varioushistoricparametersandthephysicalexaminationatthetimeofadmissionfordelivery.Jakobi
andcolleagues65foundthat:previouscesareansectionperformedforanonrepetitiveindicationsuchas
breechpresentationahistoryofaprevioussuccessfulVBACafetalstationofonecentimetersorless
abovetheischialspinesunrupturedmembranesatadmissionmorethan2yearssincethecesarean
deliveryanddilationof4cmormoreatadmissionwereallpositivelycorrelatedwithincreasedlikelihood
ofsuccessfulVBAC.Ahistoryofpreviouscesareansectionforarrestoflabor,diabetesmellitus,
hypertensioninpregnancy,inductionoflabor,oxytocinuseinlabor,andmeconiumstainedliquorwere
significantlyassociatedwithanincreasedriskofunsuccessfulVBAC.Usingthesecriteriaretrospectively,
theauthorswouldhavecorrectlypredictedthesuccessofatrialoflaborinmorethan94%ofcandidates
butwouldhavecorrectlypredictedfailureoftrialoflaborinonly33.3%ofcandidates.
FlammandGeiger66examinedsimilardatatodevelopascoringsysteminanattempttopredictthe
successoftrialoflabor.Theseauthorsfoundthatmaternalageyoungerthan40years,BMIlessthan30,
whiteethnicity,indicationotherthanfailuretoprogress,cervicaleffacementofmorethan75%on
admission,andcervicaldilationofmorethan4cmatadmissionwereallsignificantlycorrelatedwith
increasedsuccessoftrialoflabor.Whenthesefactorswereweightedandplacedinascoringsysteminan
attempttopredictthesuccessofattemptedVBAC,theauthorsfoundthatasthenumberofthesefactors
increased,thelikelihoodofsuccessfultrialoflaborincreased.Patientswithonlyoneortwoofthese
characteristicshada4959%successrate,whereaspatientswithfourormoreofthesecharacteristicshad
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agreaterthan90%successrate.Theabilitytomoreaccuratelypredictthelikelysuccessoftrialoflaboris
clinicallyuseful,becausethereisincreasedmaternalmorbidityisassociatedwithafailedtrialoflabor.67
Thesewomenhaveanincreasedriskofoperativeinjury,infectiousmorbidityanduterinerupture.
Perimortemcesareansection
Oneofthefirstindicationsforcesareansectionwasforthedeliveryofthefetusinthecaseofmaternal
death.Currently,theperformanceofarapidcesareandeliveryintheeventofsuddenmaternalcardiac
arrestisperformedtoassistinmaternalresuscitation.Ifperformedquickly,itcanbelifesavingforthe
fetus68butthisisnottheprimaryaim.Intheeventofmaternalcardiacarrestacesareansectionshould
beinitiatedwithin4minofcardiacarrest,withthegoalofdeliveringthefetuswithin5minofonsetof
cardiacarrest,wherepossible,butwhileresuscitationcontinuesitisstillworthemptyingtheuterusto
assistinmaternalresuscitationevenifthistimeframehasbeenoverstepped.
COMPLICATIONS
Maternalmortality
Asanesthesiaandoperativetechniqueshaveimproved,cesareansectionhasbecomeanincreasinglysafe
andcommonprocedurehowever,theobstetricianmustalwaysbearinmindthattheabdominaldelivery
ofaninfantisstillamajoroperativeprocedureandcanbeassociatedwithsignificantmaternalmortality
andmorbidity.Maternalmortalityaftercesareansectionhasbeenestimatedtobebetween5.81and6.1
per100,000procedures.69, 70Mostofthesedeathsresultfromthecomplicationsthatledtothe
cesareansection,butafewareasadirectconsequenceoftheprocedure.Ingeneral,thecomplications
associatedwithcesareansectionaresimilartothoseobservedafteranylaparotomy,withtheexceptionof
anincreasedincidenceofendomyometritis.Complicationsmaybedividedintothoseencountered
intraoperativelyandthoseencounteredpostoperatively.
Potentialintraoperativecomplicationsincludeuterinehemorrhagefromthesurgeryitselfbutalsofrom
inadvertentuterineangleextensions,atonyorplacentapathology.Uterineatonycontinuestobethe
majorcauseofhysterectomyatthetimeofcesareansection71, 72andisbestmanagedwithuterotonics
andmassagetheuteruswhilerepairingtheuterineincision.Additionaluterotonicsthatcanbegiven
includeergometrine(notwithhypertension),Hemabate(notwithasthma),ormisoprostol.Fluid
resuscitationandbloodtransfusionshouldbeinstitutedasclinicallyindicated.IftheatonypersistsaB
Lynchcompressionsuture72canbeinserted(Fig.10)andotheroptionsforhemorrhagecontrolinclude
bilateraluterinearteryligation,withsuturesplacedtoobliterateboththeascendinguterinearteryatthe
leveloftheloweruterinesegmentanditsanastomosiswiththeovarianarteryattheuterinecornua(Fig.
11).Thiswillcontrolbleedingfromanatonicuterusin75%ofcases.71Localizationoftheuterineartery
canbefacilitatedbycarefulpalpationofitscoursealongthelateraledgeoftheuterus.Thesurgeon
shouldthenpulltheengorgeduterineveinslaterallyintothebroadligamentandawayfromtheoperative
fieldtoavoidlacerationoftheseveinsduringsutureplacement.Isolatingtheuterinearterywitha
Babcockclampisoftenhelpfulinthesecases.Careshouldbetakentoavoidincorporatingtheureterin
theligature.73Incasesthatdonotrespondtobilateraluterinearteryligation,bilateralhypogastricartery
ligationisnolongerrecommendedbecauseitissuccessfulinlessthan50%ofpatientsandtraining
opportunitiesarenotreadilyavailable,thusanexperiencedoperatorisunlikely.Interventionalradiology
ismorecommonlyusednowandrequiresaccessviatheinternaliliacartery.Inpatientswhodonot
respondtothesemanagementstrategies,hysterectomyisappropriateandlifesaving.74
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(http://resources.ama.uk.com/glowm_www/uploads/1294479767_ch_2.74_10Capture.JPG)Fig.10.
Originallydescribedusinga7080mmroundbodiedhandneedlewithmountednumber2plainor
chromiccatgut:nowarapidlyabsorbablesyntheticsutureisrecommended.Withthebladderdisplaced
inferiorly,thefirststitchisplaced3cmbelowthelowercesareanincisiononthepatient'sleftsideand
threadedthroughtheuterinecavitytoemerge3cmabovetheupperincisionmargins,approximately4
cmfromthelateralborderoftheuterus.Now,carrythesutureontheoutsideoftheuterusoverthe
topandtotheposteriorside.Thesutureshouldbemoreorlessverticalandlyingapproximately4cm
fromthecornua.Itdoesnottendtosliplaterallytowardthebroadligamentbecausetheuterushas
beencompressedandthesuturemilkedthrough,ensuringthatproperplacementisachievedand
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maintained.Thesutureisplacedexactlythesamewayasitwasontheleftsidethatis,3cmabovethe
incision,4cmfromthelateralsideoftheuterusthroughthetopoftheincision,intotheuterinecavity,
andthenagainbackthrough3cmbelowtheincision.
(http://resources.ama.uk.com/glowm_www/graphics/figures/v2/0740/009f.jpg)Fig.11.O'Learystitch
(uterinearteryligation).Whileplacingthebroadligamentontractiontodisplacetheuterineveins
laterally,theuterinearteryispalpatedandisolated.Asutureisthenplacedbelowthelacerationtothe
uterinearterytoincorporatethearterywiththemyometrium.Ifnecessary,asecondstitchmaybe
placedabovetheincisioninthesamemanner.
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Incasesofhemorrhagenotcausedbyuterineatony,carefulexplorationoftheuterusforpossible
retainedplacentalfragmentsandexplorationoftheoperativefieldforunrecognizedlacerationsshould
beperformed.Placentalfragmentsmayberemovedmanuallyorwithaswab.Areasofplacental
adherenceshouldbeexaminedforevidenceofplacentaaccreta.Genitaltractlacerationsshouldbe
identified,isolated,andclosedinahemostaticmanner.
Urinarytractinjuries
Injurytotheurinarytractisarelativelyrarecomplicationofcesareandelivery.Theincidencesofbladder
andureteralinjuryare0.3%and0.1%,respectively.73, 75Bladderinjuriesaremorecommonwitha
historyofpreviouscesareansection.Themostcommonsiteforbladderinjuryduringcesareandeliveryis
atthedomeofthebladder.Lacerationofthebladdershouldbeevaluatedbyfirstensuringthatthe
trigoneanduretersarenotinvolved.Thismaybeaccomplishedbydirectvisualizationoftheureters
throughthecystotomy.Ifthetrigoneisnotinvolvedandtheuretersarefunctioning,thecystotomycanbe
closedintwolayersusinganabsorbablesuture.Wheneverthereisapossibilityofinadvertentcystotomy
atthetimeofcesareansection,thiscanbeevaluatedbydistendingthebladderwithsterilesalinethrough
theFoleycatheterandobservingtheoperativefieldfortheappearanceofthefluid.
Ureteralinjuryislesscommonthaninjurytothebladder.Ifthereisconcernduringtheoperative
procedurethattheureterhasbeencompromised,thesituationshouldbethoroughlyevaluatedand
consultationwithaspecialisturologistisneeded.
Gastrointestinaltractinjury
Injurytothebowelatthetimeofcesareansectionisexceedinglyrare.Anincidenceoflessthan0.1%has
beenreported.75Thislowincidenceiscausedbythedisplacementoftheboweloutoftheoperativefield
bytheenlarged,graviduterus.Theriskofbowelinjuryisincreasedinpatientswithpreviousabdominal
surgeryorintraabdominaladhesions.Injuryisusuallyobviousbecauseoftheappearanceofbowel
contentsinthesurgicalfield.Theseinjuriesshouldbequicklyidentifiedandisolatedtominimize
contaminationoftheperitonealcavity.Injurytothesmallbowelcanbeprimarilyrepairedwithatwo
layerclosureusingadelayedabsorbablesuture.Theclosureshouldbeperformedat90degreestothe
bowellumentodecreaseitsconstriction.Largerlacerationsofthesmallbowelormultiplelacerations
mayrequireresectionofalengthofbowel,andaspecialistsurgeonshouldbecalledforthisandforany
injuriestothelargebowelwhichmayrequireadefunctioningcolostomyaswellasprimaryclosure.
Woundinfections
Woundinfectionsoccuratarateofapproximately7%aftercesareansectionwhenprophylacticantibiotics
arenotgiven76thisincidenceisreducedto2%withtheuseofprophylacticantibiotics.77 Wound
infectionsthatoccuraftercesareansectionincludeendomyometritis,pelvicabscess,incisionalabscess,
andwoundcellulitis.Theantibioticofchoiceforeachinfectiondependsonthelocationoftheinfection
andthesuspectedpathogen.Antibiotictherapyshouldbeinstitutedempiricallyandadjustedasneeded
basedoncultureresults.Forpelvicabscessestreatmentincludesdrainageofpusandbroadspectrum
antibioticsincludinganaerobiccoveragearerequiredforsuperficialwoundinfections,simplyopening
theincisionanddrainingtheinfectioussourceusuallyalleviatestheprobleminpatientswhodonothave
signsofsystemicinfection.Superficialwoundcellulitiscanusuallybetreatedusingpenicillinaseresistant
penicillin.
Endomyometritis
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Endomyometritiscomplicatesupto80%ofcesareansectionsperformedafterthemembraneshavebeen
rupturedformorethan6hoursinpatientswhoarenotadministeredantibioticprophylaxis78and30%in
patientswithintactmembranes.Theincidencehasbeenshowntobehighinpatientpopulationsoflower
socioeconomicstatus,inpatientswhohavehadsixormorevaginalexaminationsduringlaborandin
patientswithlongerdurationofruptureofmembranes.79Therateofuterineinfectioncanbereducedto
5%orlesswiththeuseofprophylacticantibioticsgivenatthetimeofcordclamp.80Asingledoseofa
broadspectrumantibioticisrelativelyinexpensiveandeffectivelydecreasestheinfectionrate.
Incompletescarhealing
Adeficientcesareansectionscarhasbecomeoneoftherecognizedcomplicationsassociatedwiththistype
ofoperation.Theexactcauseandmechanismofincompletehealingofthescarandwhetherthisleadsto
functionaluterinedeficiencyisnotwellunderstood.Asmorewomenundergotransvaginal
ultrasonography,themorphologyofsectionscarshascomeunderincreasingscrutiny.Currentlyitisnot
knowniftheappearancesofacesareansectionscarusingultrasoundtranslateintoanyrelationshiptothe
functionalintegrityoftheuterus,riskofectopicpregnancy,pathologicalplacentation,uterineruptureor
performanceinlabor.Thereisanurgentneedtoexplorethisrelationshipsothatwecanunderstandhow
tointerpretimagesoftheuterusfollowingcesareansectionandtheimplicationsofvarioustypesofscar
onpatientmanagement.Studyingthenaturalhistoryofcesareansectionscarinthepregnantstateand
followingittodeliverycouldachievethis,andanalyzingwhethercertainscarfeaturesonultrasoundscan
canleadtoasuccessfulvaginaldeliveryorarepeatcesareansection.
Thereisgrowingevidencetosuggestthatcompletehealingofthepreviouscesareanscarandmyometrial
thicknessattheloweruterinesegmentareimportantfactorsinachievinguneventfulpregnancyoutcome,
whetherbyERCDorVBAC.81Overthepast10yearstherehavebeenmultipleattemptstostudythese
factorsbyultrasonographyanddifferentreportshavebeenpublishedintheliteratureregardingthe
prevalenceandtheclinicalsignificanceofincompletelyhealedcesareanscars.82VBACisconsideredtobe
asafealternativetoERCDwhentheriskofuterineruptureinminimal,andasmentionedaboveseveral
factorsmustbeexaminedbeforeconsideringthisoption.65However,tobetterassesstheriskofuterine
rupture,someauthorshaveproposedsonographicmeasurementofthecesareanscarandthethicknessof
theloweruterinesegment,assumingthatcertainscarfeaturesandcutoffvaluesarecorrelatedwiththe
uterinescardefect.83Theseultrasoundmeasurementsmayincreasethesafetyoflaboraftercesarean
sectionbecausetheyprovideadditionalinformationontheriskofuterinerupture.Recentevidencealso
statesthattransvaginalultrasoundscanisareliableandreproduciblemethodformeasuringthe
myometrialthicknessnearterm,83andconcludesthatthisvaluemayserveasapredictorofuterinescar
defectinwomencontemplatingVBAC.However,anidealcutoffvaluecannotberecommendedyet,
underliningtheneedforfurtherwelldesignedprospectiveandlongitudinalstudiesduringpregnancy.
Uterinescarrupture
Inspiteoftherecentadvancesinmodernobstetricpractice,ruptureofthepregnantuterusisstilloneof
themostlifethreateningcomplicationsofpregnancy,anditisassociatedwithhighratesofmaternal
morbidityandfetalmorbidityandmortality.84Previouscesareansectionhasbeenshowntobethemost
importantriskfactor,85butnodifferenceintheoutcomeoflaborwithregardtouterinerupture,
betweenwomenwithandthosewithoutpreviouscesareansectionhasalsobeenreported.84Themost
commonlyquotedscarruptureforlowersegmentcesareansection(LSCS)is0.5%,oronein200.86
Theincidenceofuterinerupturemaybeincreasedinpatientswithaprevioussinglelayerclosure.47 , 48,
49, 50, 87 However,inpatientswithapreviousclassicuterineincision,theriskofuterinerupturemaybe
ashighas9%,withonethirdoftheseoccurringbeforetheonsetofclinicallabor.88Inonestudyon
89
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pretermcesareansectionstheriskofuterinerupturewassimilarforbothtypesofuterineincision.89In
theeventofuterinerupture,fetalmortalityandmorbidityarehighlysignificant.Whenaclassicuterine
incisionruptures,thefetalmortalityisinexcessof50%,comparedwith12%intheeventofruptureofa
priorlowtransverseincision.90
Futurefertility
Womenwhohavehadacesareansectionarelesslikelythanthosewhohavehadavaginaldeliverytohave
furtherchildren,butitishardtoseparateoutthereasonsforthisintermsofvoluntaryfamilyplanning,
consequencesoftheindicationsforthecesareanandduetotheactualoperation.Thereappearstobea
lesserdesireforfurtherchildrenaswellasadecreasedabilitytoconceive.91Thereisaconcept
developingthatabnormalscarhealingmayaffectendometrialreceptivityaswellasuterinecontractility
duetoabnormalsignaling,andthisisbelievedtocompromisetheuterinefavorabilityforsuccessful
implantation.92However,nohardevidencehasbeenestablishedtosupportthis.BenNagi92recently
hypothesizedthepossibilityofalinkbetweenaltereduterineimmunobiology,LSCSandembryo
implantation.TheystudiedtheeffectofLSCSontheendometriuminpremenopausalwomenwithhistory
ofLSCStheytookendometrialsamplesfrombothcesareanscarsiteandposterioruterinewall,and
comparedtheresultswithsimilarsamplesobtainedfromwomenwhohadspontaneousvaginaldelivery
(SVD).Themostsignificantdifferencefoundwasfewerleukocytesandlessvascularizationatthescarsite,
thanintheendometriumoftheunscarreduterus.Inaddition,theyfoundadelayinendometrial
maturationatthescarsite,andthisdelaymighthavebeenaresultofdisruptioninsteroidreceptor
expression,leadingtoabnormalresponsetoestrogenandprogesterone.Thesestudiesraised
considerableinterestandemphasizedthatendometriumatLSCSscarsitemaynotcycleinsynchronywith
therestofendometriumintheuterinecavityhowever,furtherstudiesarerequiredtoexplorethis
hypothesis.
CONCLUSION
Overthepastseveraldecadestheincidenceofcesareandeliveryhasincreaseddramatically.Althoughthe
operationcontinuestobecomesafer,theincidenceofmaternalmortalityandmorbidityisstillsignificant.
Continuedeffortsonthepartoftheobstetricianmustbemadetoensurethatcesareandeliveriesarenot
performedforinappropriateindicationsandthateachwomaniscounseledcarefullyaccordingtoher
individualcharacteristics.Everyeffortshouldbemadetoallowthepatienttodelivervaginallywhenfetal
andmaternalstatusesarereassuring.Whenacesareansectionisindicatedandembarkeduponthe
preparationshouldbeascarefullyplannedastimeallows,andthesurgicaltechniqueshouldadhereto
goodsurgicalprinciples.Continuingresearchisrequiredtoevaluatespecifictechniquesofthecesarean
operationfurther,particularlyrelatingtouterineclosureandscarintegrityinthelongerterm.
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